A CASE OF ACUTE INFECTIVE ENDOCARDITIS AND SEPTIC SHOCK A CASE OF ACUTE INFECTIVE ENDOCARDITIS AND SEPTIC SHOCK

. Infective endocarditis (IE) marks an increasing morbidity and unchanged mortality despite advances in its diagnosis and treatment. In about 20% of IE cases are acute, with signs of sepsis and septic shock. Septic shock dramatically worsens prognosis and is an independent predictor of in – hospital death. Timely diagnosis and urgent surgical intervention can improve survival in these patients. We present a case of a 47-year-old man, with no history of past or concomitant diseases, who was admitted as an emergency to the Cardiology Intensive Care Unit, during the Covid-19 pandemic, with pronounced febrile-intoxication syndrome, shortness of breath, precordial discomfort and pain, cough, haemoptysis. From laboratory studies with a pronounced in ﬂ ammatory constellation, troponin I and D-dimers are also increased. This case shows the dif ﬁ culties in the diagnosis of acute IE, the speci ﬁ cs in the clinical course of the disease, as well as the importance of urgent surgical intervention to improve survival.


I
Infective endocarditis (IE) is an inflammatory disease of the endocardium of the valves and the valve prostheses, and in the last few decades also of intracardiac catheters and devices.The disease has constantly changing characteristics in terms of age, comorbidity, predisposing cardiac conditions, microbiological causative agent, clinical presentation, but with unchanging and high in-hospital mortality up to 20-30% [1].Cases of acute IE are associated with a complicated clinical course and often with an unfavourable outcome [2].Acute IE is defined when the time from onset of symptoms to diagnosis is less than 15 days.Usually affecting native valves, caused by highly virulent microorganisms such as Staphylococcus aureus, B-haemolytic streptococci, Streptococcus pneurnoniae, and Neisseria gonorrhoeae, which cause rapid destruction of the valves [2].Pseudomonas aeruginosa and Serratia marcescens are more common in intravenous drug users.Sepsis and septic shock are common clinical manifestations of acute IE and are a sign of unfavourable prognosis and high mortality -up to 73% [3].Septic shock has been identified as an independent predictor of in-hospital death [1,3,4].Timely diagnosis and the decision for urgent surgical intervention, when it is possible, improve survival in these patients.
X-ray -evidence of congestive changes in the lung, and superimposed infi ltrative ones cannot be excluded (Fig. 2).
Chest CT with aortography and pulmonary angiography was performed.Lung parenchyma -areas of "ground glass opacities" type consolidation are established bilaterally, parahilar.Bilateral pleural eff usions are visualized, on the right -930 ml and on the left -600 ml.Highlighted interstitial lung structure.Single enlarged paratracheal lymph nodes.Cardiomegaly.Conclusion: The described interstitial changes could be defi ned like congestive or infi ltrative-infl ammatory, and pulmonary edema cannot be excluded.From aortography no evidence of aneurysm or dissection.The performed pulmonary angiography ruled out pulmonary embolism (Fig. 4 A, B, C).
Three blood cultures and 3 urine cultures were taken, according to protocol, before starting antibiotic treatment on the day of hospitalization.For blood cultures were used ready-made bottles of BacT/ALERT liquid nutrient media (bioMerieux, France) allowing the cultivation of aerobes, anaerobes and fungi.
При нашия пациент първоначалната работна диагноза е COVID-19 асоциирана пневмония и obtained on the 7th day of hospitalization (postoperative).The intraoperative histological material was also without microbiological identifi cation.Blood cultures and histological material from the tissue was sterile, probably due to the previous antibiotic treatment.
Postoperatively, several more hemodiafi ltrations and double AB therapy for 30 days -cefoperazon/sulbactam -2 x 1 g.i.v.+ levofl oxacin -500 mg i.v.days, 10 days, Teicoplanin and Vancomycin for 20 days.No complications during the stay.Permanently afebrile Normalized kidney and liver function, without signs of heart failure.Fully rehabilitated.One year follow-up without any complications.

D
Acute IE often presents or is complicated by sepsis or septic shock.These conditions sharply worsen the prognosis and increase the risk of death.Sepsis is a life-threatening organ dysfunction that results from the dysregulation of the body's response to infection.It is recommended that the SOFA score be used to determine organ dysfunction, acute changes of ≥ 2 points due to infection compared to baseline in the total score are diagnostic of sepsis [5].The baseline SOFA score should be taken as zero, except in cases of known pre-existing (acute or chronic) organ dysfunction before the onset of infection.Patients with a SOFA score ≥ 2 points have an overall mortality risk of approximately 10% of the total hospital population with suspected infection.Depending on baseline risk, a SOFA score ≥ 2 was associated with a 2-to 25fold increased risk of death compared with patients with a SOFA score < 2. The new simplified model -qSOFA (quick SOFA criteria) includes three clinical variables: impaired consciousness (Glasgow scale score ≤ 13), systolic arterial pressure < 100 mmHg; respiratory rate > 22/min.Finding two of these variables measured outside the ICU has similar predictive value to the full SOFA score.
Septic shock is a complication of sepsis in which the underlying circulatory and cellular/metabolic disturbances are so severe that they lead to a signifi cant increase in mortality.Thus, patients with septic shock can be clinically identifi ed by the need for vasopressors to maintain a mean arterial pressure ≥ 65 mmHg and a serum lactate level > 2 mmol/l in the absence of hypovolemia.This combination is associated with an in-hospital mortality rate of > 40% [6].
Продължителността на антибиотичната терапия след операция на активен ИЕ продължава да е обект на дебат.Обичайно се предписват дълги антибиотични курсове на лечение, поради страх от инфекция на имплантираната/реконструираната клапа.Според последните европейски и американски препоръки се препоръчва 4-6 седмично антибиотично лечение, когато тъканните култури от резецираните клапи са положителни [9,10].V. P. Rao и съавт.не намират връзка между продължителността на лечението и случаите на рекурентен ИЕ или смърт при 182 случая със средна продължителност на антибиотичното лечение след операция 23.5 дни (IR 12-40).Така избрани пациенти могат да получат по-кратък следоперативен антибиотичен tis, based on the febrile -intoxication syndrome, the absence of previous diseases, lung "ground glass" type changes from chest CT, ECG, echocardiographic and laboratory changes.He had evidence of sepsis during hospitalization, SOFA score 3pts, progressed to 8 pts in 2 days.There are signs of septic shock on day 3 -need for pressor amines, low systolic BP < 80 mm Hg and increased serum lactate -4.5 mmol/l.Due to the rapid dynamics and evolution of the disease, repeated echocardiographies, in case of clinical suspicion, are extremely important for the diagnosis.The patient did not undergo transesophageal echocardiography (TОE) on admission because IE did not appear in the initial differential diagnosis plan.On the other hand, mild and moderate regurgitations, of a degenerative type, which were not diagnosed, are often found.Categorical evidence of vegetations and severe aortic regurgitation from the repeat echocardiography and the extremely severe condition of the patient were reasons for not performing TОE.Acute IE was diagnosed as probable, according to the Duke criteria, based on the presence of vegetations and severe acute aortic regurgitation, fever, and inflammatory markers, with no blood culture results available by day 3. Severe aortic regurgitation, physical and CT findings of pulmonary edema and pleural effusions, low systolic blood pressure, tachycardia and oliguria suggest a diagnosis of cardiogenic shock.Septic and cardiogenic shock are indications for urgent operative intervention.Early operative intervention in acute IE reduces mortality by 64% [7,8] and improves prognosis.Timely diagnosis of acute aortic valve IE complicated by severe aortic regurgitation, cardiogenic and septic shock and the decision for emergency valve replacement are crucial for the good outcome of the disease.

Библиография // References
a shorter postoperative course of antibiotic treatment without aff ecting recurrence rates of IE or survival [11].Our patient received a 30-day postoperative antibiotic treatment, with a double combination.No evidence of IE relapse up to 1 year after surgery.The individualized approach applied by the endocarditis team to the type and duration of postoperative antibiotic treatment is the basis for the good short-term and long-term results.

C
Acute IE aff ects more often intact valves.Clinical diagnosis is diffi cult because the symptoms may resemble other infectious diseases -pyelonephritis, infl uenza, pneumonia, meningitis, infectious mononucleosis, rheumatic disease, etc. Mortality is high -up to 70-80%.Timely diagnosis gives a chance for life.Repeated echocardiographies, in case of clinical suspicion, are extremely important for the diagnosis.Initial empiric antibiotic treatment and the decision for urgent surgical intervention are crucial for the outcome of the disease.